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This case presentation describes a 4-year-old female patient from Cairo diagnosed with Acute Myeloid Leukemia M3. She initially presented with persistent fever, pallor, and significant blast cells in her blood tests. Following multiple treatment regimens including induction chemotherapy, craniospinal radiotherapy, and management of complications such as chest infections and pleural effusion, the patient experienced a hematological relapse with CNS manifestations. Comprehensive evaluations and empirical treatments led to marked clinical improvement and complete remission.
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Patient’s History • A. Y. female patient 4 years old is living in Cairo • Presented outside NCI by • Persistent fever • Pallor • Outside NCI CBC: 55% blasts
Clinically • Fair general condition • Pallor • Symptoms of increased ICT • No other neurological deficit • No organomegaly or lymphadinopathy • Chest, heart, & abdominal examination: free
Investigations • CBC: TLC 7500, ANC 500, Hb 6, Plt 65000 • BM aspiration: AML M3 • IPT: myeloid CD 33, 13 MPO +ve • Cytogenetics: 46 XX t 15-17 • CSF: ++ve • Brain MRI: normal • Chest x-ray & abdominal US: free
Treatment • Induction: • ADR 45 mg/ m2 (d 1, 2, & 3) • ATRA 45 mg/ m2 till remission • Intra thecal weekly • Consolidation: • 2 courses of ADR 45 mg/ m2 (d 1, 2, & 3)
She was planned to receive craniospinal radiotherapy • & to be put on maintenance chemotherapy • MTX 20 mg /m2 weekly • 6 MP 75 mg / m2 • ATRA 45 mg /m2 for 2 weeks every 12 weeks • Radiotherapy was postponed due to poor chest condition
Chest condition • Fever • Respiratory distress Gr III • Neutropenia • Chest x-ray: pleural effusion Chest Infection ATRA Syndrome Malignant effusion Plural effusion cytology: -ve Stopped chemotherapy
Chest Infection • Broad spectrum antibiotic • Follow up chest x-ray: • encysted pleural effusion • CT chest: • pleural based mass with central • breaking down • Sputum C&S: • Many cndidal colonies • Amphotercin B was added Re evaluation after 2 weeks • Follow up chest CT: • no appreciable changes • Another sputum C&S: • gram +ve cocci only sensitive to vancomycin • Vancomycin was added for 2 weeks • Follow up chest CT: • marked improvement
After improvement of the chest condition, the patient received • Craniospinal irradiation • Continued maintenance chemotherapy
Seven months later, the patient had • Hematological relapse • CBC: TLC 16000, Hb 9.6, Plt 26000, blasts 57% • BM aspirate: • AML M3 in relapse • 20% blasts • CNS manifestation
CNS disease • Fever & headache • Convulsions • Aphasia • Blurring of vision • Neck stiffness • Behavioral changes • Leukemic infiltration • Suspected due to • Previous history of CNS infiltration • hematological relapse • CNS Infection • Suspected due to: • Fever & • neck stiffness Empirical ttt by Brain dehydrating measures • Salvage chemotherapy • Intra thecal injections • Anti bacterial • Acyclovir &
Results of Investigation Empirical treatment was continued until the collection of data from • Radiological investigations: MRI revealed: Lt tempro-parieto-occipital infiltration with lepto-meningeal distribution & gyral edema
Laboratory investigation • CSF analysis: • High TLC • High protein content • Normal sugar & Chloride content • CSF C & S: • +ve for HSV type I by monoclonal antibodies • -ve for bacterial & fungal growth
Revaluation by BM aspirate revealed Complete Remission CNS condition markedly improved
Plan of future treatment RT PCR for t 15-17 +ve -ve Allogenic BMT Auto BMT
